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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701152
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:59:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20230501151100
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Nadine Mills and Charlotte LewisTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not dispense medications as prescribed.
Staff did not provide adequate meals for resident.
INVESTIGATION FINDINGS:
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On 05-05-2023 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to open a complaint investigation with the above allegations and close the investigation. LPA Martinez met with Nadine Mills and Charlotte Lewis and explained the purpose of today's visit.

During today's complaint investigation, LPA Martinez reviewed two medication files. Resident 1's (R1) Medication Administration Record (MAR) was not properly maintained. The May 2023 MAR sheet is missing medication entries for the following: Alodipine 5MG, Xarelto 20MG, Gabapentin 300MG, Omeprazole 20MG, Lisinopril 20 MG, Albuterol 0.083 % 3ML, Combivent Respimat AER BOE, Trueplus Ultra Thing 30G L, True Metrix Glucose. Furthermore, R1 has a 04/24/2023 doctor's order stating..."R1 has been treated to take Gabapentin 600 MG tablet take 1 three times a day." However, R1's MAR states Gabapentin 25 MG 1 tablet by mouth 3 times per day was administered.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20230501151100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
VISIT DATE: 05/05/2023
NARRATIVE
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R2's MAR entry for Olanzapine is incorrect. The MAR only has one entry for Olanzapine , which the resident has two separate orders for this medication. R2 has an order for Olanzapine 10MG tablets take one tablet by mouth in the Morning, the second order is to take one tablet by mouth at bed time. However, the MAR states Olanzapine Dose: 10MG take 1 tab by mouth in the morning and take 2 tablets at bed time. As a result, the facility is not following doctors orders and prescription bottle order labels.

Additionally, R1's medication prescription bottles were found in Resident 3 (R3) medication box. LPA Martinez was informed by staff 2 (S2) that R1 had observed their medication in R3's medication box. In addition, R1 reported observing their medication in R3's medication box during a medication pass, and refused medication during this pass. R1 did not consume medication that was not prescribed to them.

Moreover, During today's visit, LPA Martinez observed S1 serve R1 a prepared breakfast meal. The breakfast for today was toast, sliced hard boiled eggs, and fruit. LPA observed and heard R1 inform S1 that they could not eat toast and fruit due to a chewing food issue, which is an ongoing issue. R1 then proceed to eat part of the eggs, and left the rest. As a result, R1 was provided a meal that was not suitable for their care needs.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility. Also, please refer to May 5, 2023 809 report for additional deficiencies.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230501151100

FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:GARCIA, DIANAFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
05/05/2023
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Nadine Mills and Charlotte LewisTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On 05-05-2023 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to open a complaint investigation with the above allegations and close the investigation. LPA Martinez met with Nadine Mills and Charlotte Lewis and explained the purpose of today's visit.

During today's investigation, LPA Martinez conducted interviews and reviewed facility files. LPA reviewed R1's Client/Resident Personal Property and Valuables form. The form indicated R1' declined to fill out the document, and R1' signature and date was noted on the form. It is unknown at this time, what personal items R1 brought into the facility. LPA Martinez was informed the reported missing item 1 was not brought into the facility during R1's initial move in. Moreover, staff 2 (S2) reported the missing item is being replaced and should take 1 month to receive the item. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230501151100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4)Incidental Medical and Dental Care...A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:
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Facility agrees to: conduct a medication audit by POC Date 05/11/2023. Medication Audit documentation should be emailed to LPA Martinez by 05/11/2023 by 5 PM.
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Based on observation and file review, the Licensee did not ensure to assist R1 and R2 with their self administered medication as needed. This posed a potential health and safety risk to R1 and R2.
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Type B
05/26/2023
Section Cited
CCR
87555(b)(2)
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87555(b)(2) General Food Service Requirements:The following food service requirements shall apply:Where meal service within a facility is elective, arrangements shall be made to assure availability of an adequate daily food intake for all residents... this requirement was not met as evidence by:
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Facility staff agrees to incorporate foods that R1 is able to chew. Staff also agrees to conduct a reassessment to include R1's new physical health status changes by POC Date 05/26/2023. Staff will email reassessment to LPA Martinez by POC date 05/26/23 5 PM.
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Based on observation, the Licensee did not ensure R1 was provided adequate daily food intake during BF. This posed a potential health and safety risk to R1
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4